OBJECTIVE -The goal of this study was to evaluate whether simple risk factors can be identified that successfully characterize who will heal and who will not heal among patients who have received standard therapy for diabetic neuropathic foot ulcers.RESEARCH DESIGN AND METHODS -For this cohort study, we evaluated Ͼ31,000 individuals with a diabetic neuropathic foot ulcer seen in the Curative Health Services System. Using multivariate logistic regression, we evaluated the association between wound size, wound duration, wound grade, and other variables and their effect on whether a patient would heal by the 20th week of care.RESULTS -We demonstrated that wound size, wound duration, and wound grade are all significantly associated with the likelihood of a wound healing by the 20th week of care. In addition, we noted that these associations were not significantly affected by the treating wound care center, whether the unit of analysis was one wound on a patient or all of their wounds, or current adjuvant therapies.CONCLUSIONS -We have shown that three easy-to-measure risk factors are associated with a wound healing. These results should help clinicians understand the likelihood that a wound will heal and help those conducting clinical investigations to design better trials. Diabetes Care 25:1835-1839, 2002L ower-extremity ulcers are a serious complication of diabetes. More than 16 million people in the U.S. have diabetes, and 15% of them can expect to develop a foot ulcer at some point in their lives (1-3). Diabetic patients admitted to the hospital with lower-extremity ulcers were hospitalized longer on average than those who were hospitalized and did not have ulcers (1,3). Whereas only 4% of the population has diabetes, 46% of those admitted to a hospital with a foot ulcer had diabetes, and half of all lower-extremity amputations in hospitalized patients occurred in diabetic patients (1,3). Those with a lower-extremity amputation have a diminished quality of life and increased health costs, often have many concomitant medical ailments, are more likely to have the contralateral limb amputated, and are more likely to die within the next 5 years than those with no amputation (4,5).There are many pathways for the development of a diabetic foot ulcer. In general, they include a combination of lowerlimb arterial insufficiency, lower-limb diabetic neuropathy, and local trauma (6). About 20% of diabetic patients with foot ulcers will primarily have inadequate arterial blood flow, ϳ50% will primarily have diabetic neuropathy, and ϳ30% will be afflicted with both conditions (1,6). Inadequate arterial blood flow is usually treated by a variety of surgical techniques that improve blood flow (7). For this study, foot ulcers on individuals with diabetes who lack protective sensation and have adequate arterial blood flow to their foot are termed diabetic neuropathic foot ulcers (DNFUs) (8 -10).The treatment of a DNFU usually consists of debridement of necrotic tissue, use of a moist wound dressing, and the use of a device that p...

Venous leg ulcers are among the most common chronic wounds. Treatment is commonly with a limb compression bandage. Previous small, often single-center, studies have shown that it is possible to predict which wounds are likely to respond to compression therapy. We designed this cohort study using a dataset of over 20,000 individuals with a venous leg ulcer to investigate the accuracy of several prognostic models. Creating complex models using logistic regression, as well as simply counting prognostic factors, we show that initial measures of wound size and duration accurately predict, as measured by area under the receiver operator curve and Brier score, who will heal by the 24th week of care. For example, a wound that is less than 10 cm(2) and less than 12 months old at the first visit has a 29 percent chance of not healing by the 24th week of care, while a wound greater than 10 cm(2) and greater than 12 months old has a 78 percent chance of not healing. Ultimately, these models can be applied by a clinician to help determine whom to continue to treat with standard care and perhaps whom to treat with adjuvant therapies. They may also aid in the design of clinical trials.

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We have shown that individuals with a diabetic neuropathic foot ulcer seeking care are more likely to heal today than 10 years ago. The primary reason for this improvement is that individuals are seeking care when their wounds are most easily treated and these are now more likely to heal.

A neuropathic foot ulcer is a severe complication of diabetes that can result in a more severe complication, a lower extremity amputation. We conducted a cohort study of 24,616 individuals with a diabetic neuropathic foot ulcer treated within a multicenter wound care network. A total of 1653 (6.7%) individuals had an amputation and 46.3% of these amputations were of a toe or ray (minor amputation). In the more than 10-year follow-up period that we studied, the percentage of those who had an amputation varied between 5.6% and 8.4%. Of those who had an amputation, the percentage that had a minor amputation increased over time from 4.0% in the earliest years to more than 60% in the later years of observation. The single most important determinant of amputation was the observation of fascia, tendon, and bone at the initial assessment. In conclusion, about 7% of those with a diabetic neuropathic foot ulcer will have an amputation and in the past 10 years there has been a remarkable increase in the number of minor as compared to major amputations.

Objective To investigate the accuracy of serial hCG to predict outcome of a pregnancy of unknown location in an ethnically and geographically diverse setting. Design Multi-site cohort study Setting University hospital Patients Women with a pregnancy of unknown location Interventions None Main outcome measures Patients were followed until diagnosed with ectopic pregnancy (EP), intrauterine pregnancy (IUP), or miscarriage. To predict outcome, observed hCG was compared to recommended thresholds to assess deviation from defined normal curves. Predicted outcome was compared to standard of care. Sensitivity, specificity, predictive value, and accuracy were calculated, stratified by diagnosis. Results The final diagnosis 1,005 patients included 179 EPs, 259 IUPs, and 567 miscarriages. The optimal balance in sensitivity and specificity used the minimal expected two-day rise in hCG of 35%, and the minimal two-day decline in hCG of 36–47% (depending on the level) achieving 83.2% sensitivity, 70.8% specificity to predict EP. However 16.8% of EPs and 7.7% of IUPs would be misclassified solely using serial hCGs. Consideration of a third hCG and early ultrasound decreased IUP misclassification to 2.7%. Conclusion Solely using serial hCG values can result in misclassification. Clinical judgment should trump prediction rules and continued surveillance with a third hCG may be prudent, especially when initial values are low or when values are near suggested thresholds.

Among psychiatric patients, hyponatremia is often associated with factors other than psychogenic polydipsia, including medications and medical comorbidities. Although elderly psychiatric inpatients seem to develop hyponatremia more often than younger patients, once drugs and comorbidities are taken into account, age does not appear to be a significant risk factor for hyponatremia in this population.

Adolescents' specific knowledge about non-HIV STDs is only cursory, despite their reports of having received education about STDs. We must attempt to improve and balance our STD education so that adolescents receive and retain detailed age-appropriate STD information that is consistent with their risk for disease.